Orthotist Lobby?

We
can criticize socialized health care, citing statistics and chronicling
the historical record of runaway costs and deterioration of quality.
But you have to deal directly with Medicare and Medicaid (or perhaps be
a former Soviet citizen) to really appreciate the Twilight Zone nature
of government-run programs.

Among federal Medicare regulations
-- which are over 130,000 pages long -- there is more than ample room
for confusion and some humor. After a long search for traction weights
(those five pound blocks of metal used to pull fractures out to length)
I found them propping open doors to patient rooms in the ER. It is a
punishable offense under Medicare regs if the hospital is caught
propping open these doors because they are fire doors.

In 30
years, I have never seen nor heard of a significant hospital fire.
However, patients suffer every day by being inadequately monitored.
Keeping these “fire” doors closed means the nurse sitting at her desk
outside the rooms cannot visually monitor the patients. But, to comply
with regulations, all those little rubber doorstops were thrown out.
Fortunately, given a choice between poor patient care and ignoring a
government mandate, most nurses care more about the patient than about
the wishes of a bureaucrat in Washington. Ergo, the nurses
commandeered the orthopaedic traction weights. In case of a pop
inspection, traction weights at least provide plausible deniability.

Medical
"quality" gurus of the Center for Medicare Services are convinced that
certain abbreviations are dangerous. After over 100 years of clinical
use, we can no longer write MS for Morphine Sulphate because it may be
confused with Magnesium Sulfate -- two drugs with totally different
indications. Neither can we write MagSO4 for Magnesium Sulfate, even
though it is the technical chemical name for the drug. We cannot write
‘cc’ (an abbreviation every junior high science student understands)
because it might be confused with ‘i.u’.-- international unit. And, we
can't use ‘i.u.’ because -- you guessed it -- it might be confused with
‘cc’!

Like good gulag inhabitants, doctors complied for a
while, then some (no one I know, of course) committed little acts of
defiance such as making up their own abbreviations because the
government watchdogs simply cannot enumerate all the outlawed terms --
though God knows they have tried.

As Medicare decreased
reimbursements, physicians found ways of being more efficient while
maintaining quality -- presumably the kind of behavior any third-party
payor would want. In my case, I used a physicians' assistant to help
gather routine data during a new patient encounter. He would do the
routine part of the history and physical, and I would do the complex
part, utilizing my time explaining the problem and treatment options to
the patient. But this quality care was not to be. Medicare decided it
would pay me approximately $94 for a new patient visit if I did it all
myself (but I would waste much of our visit doing the mundane part of
the exam) or it would pay the PA $94 if he did it all himself, as long
as I was present to sign off on his plan. That option would have been
more lucrative, but a clear compromise of care since I would have been
signing off on a plan without first-hand patient knowledge. The quality
solution which we had at first implemented would also have been $94 and
superior in every way, but this was deemed illegal, subject to a
$10,000 fine for being a "split consult" -- we both can’t see the same
patient the same day and bill as one.

After four years of
medical school, five years of residency, and usually a year or two of
fellowship, orthopaedic surgeons are the most qualified people to apply
splints. Up until last year, I did so. But now, Medicare has determined
that only those physicians who are "certified" may do so. Who will
certify me, you may well ask? A group of orthotists -- people with no
medical degree and (relative to orthopaedists) much more limited
experience and training? And this certification would have cost me over
$3000 -- a cost exceeding the revenue for placing splints on Medicare
patients in my practice.

So, now, these older patients, when
taken out of a cast, must travel to another facility, to have a less
qualified provider give them a vastly more costly splint. And, the
physician can not oversee the process to insure correctness of the
application. Medicare is paying more for less quality. (I guess the
orthotist lobby is more powerful than the orthopaedic lobby.)

These
are not isolated incidents, but emblematic of a daily clinic in
Medicare Absurdistan. A psychiatrist once told me that we need three
things to remain sane -- the ability to deflect criticism, the ability
to laugh at oneself, and the ability to accept the absurd. Until it
kills us, government run medicine should provide no end of practice.

Lee
Hieb is an Orthopaedic Surgeon, in solo private practice. Her
first-hand experience in medicine began in the 1950s, when she
accompanied her father on his housecalls in Iowa.